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The Real Value of an Interactive, Self-Ligating Bracket by Ron Roncone, DDS, MS

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It seems that nothing in orthodontics has an easy, clear-cut answer.

Whether extraction or non-extraction, cephalometric analyses, traditional twin or self-ligating brackets, or passive, active, or interactive self-ligating brackets (SLB), the answers are rarely obvious.

Perhaps there is no single answer in those areas because so many different approaches work! I certainly know many orthodontists who do superb orthodontics using very different types of brackets, wires and techniques.



So, are there really any differences in brackets? The answer is yes and no. Brackets are much more than a simple device placed on a tooth.
  • It is part of a "prescription"
  • It is, or can be, more or less efficient
  • It is, or can be, esthetic
  • It can be better or worse in
    • bonding effectiveness
  • It places teeth in great position only if it is placed correctly on the tooth
  • It can be very expensive to very inexpensive
  • It can be a major part of an orthodontist's "being" or even self-worth
So, what type of bracket do I prefer, and why? I cannot imagine any set of circumstances that would place me in a position to ever use any bracket other than an SLB. The modern advent of self-ligation had the possibility of bringing significant efficiencies to an orthodontic practice. Some SLBs do and some do not.

Over the years, I have tried almost every type of SLB, including passive, active, and interactive. These SLBs have included Edgelock, Speed, Activa, In-Ovation, Damon, SmartClip, Empower, and many others. In addition, lingual self- ligating brackets are a huge advantage over non-SLB's.

My choice has evolved to the Foresta dent BioQuick and QuicKlear.

The remainder of this paper will be devoted to the use and advantages of the interactive SLB. Those areas with an asterisk pertain only to the Forestadent SLBs.

Our practice has been dedicated to esthetic orthodontics for more than 30 years, so ceramic SLBs are the cornerstone of everything we do. Ideally, the perfect bracket (which has not yet been created) should be:
  • Very esthetic and stay that way
  • Very efficient
  • Reasonably priced
  • Very reliable in bond strength
  • Easily removable when desired*
  • Have a replaceable clip or door*
  • Have the ability to efficiently
finish cases
The PDS QuicKlear bracket has all of these qualities plus one additional quality. The bracket can be easily removed and replaced when necessary using Paul's Tool. This saves an enormous amount of money since a new bracket is not necessary.

It is, in my opinion, the very best active, ceramic SLB. Any non-SLB ceramic bracket immediately becomes non-esthetic when a clear elastomerics tie is used, or a so-called tooth-colored steel tie is used. It also becomes very non-efficient since the patient has to return very often to change elastomerics. The price is very reasonable compared to other SLBs or even non-SLBs. Bond strength is superb because of one piece of undercut design.

It is a great marketing tool also. Patients have been begging for esthetic orthodontics for years, yet orthodontists have been reluctant to give it to them for a variety of invalid reasons.

Case presentation
A case that is not truly typical follows. It took about five months longer than typical PDS treatment for full-bonded cases and two appointments more than average.

Let's discuss this case. The vast majority of my cases (90 percent) are finished in 11 to 15 months and in seven appointments, including initial bonding and removal. What about the other approximately 10 percent? This is one of those cases. Our typical case begins with two .014 PDS superelastic wires kept in place for a minimum of six months, followed by an upper .019 x .025 PDS Beta "P" loop on the upper and .019 x .025 PDS Beta Ideal wire on the lower.

In this case, an upper Roncone Hyrax was used to expand and advance the maxilla and regain some space during Phase I.

Analyses before Phase II show end-to-end anterior small maxillary second premolars, small maxillary laterals compared to the lower and somewhat fan-shaped lower incisors. The plan of treatment for this patient was to use .018 PDS HANT wires to get initial alignment and make space for the upper canines. The same wires were left in place for six months, at which time a lower .020 x .020 PDS HANT wire was placed.

Two months later, upper canine brackets were placed and the same .018 PDS used.

Eight weeks later, a .020 x .020 PDS HANT was placed in the upper to ensure enough labial crown torque to the upper incisors.

We used the same finishing wires as is typical. The "P" loop in the maxilla can be adjusted (and was) by an intraoral adjustment which places a step down (for anterior guidance) and labial crown torque (lingual root torque).

Anterior guidance was achieved even with minimum overbite in this patient because cusps of posterior teeth were not steep and the TMJ eminence was also not steep.

Slight IPR was done on lower incisors and lower premolars.

Two brackets were removed and replaced for proper positioning—the lower right second premolar and the upper right central. Because the QuicKlear bracket on the central is easily removed in one piece without any damage, the base was microetched and rebonded.



Conclusion
So why use self-ligating brackets?
  1. Appointment efficiency—If a practice were to see 50 patients per day, two weeks could be saved each year.
  2. If using a ceramic SLB—Superb esthetics all through treatment. No yellow elastic ties. To keep non-SLB ceramics looking great, the patient would need to be seen every three weeks.
  3. In combination with efficient mechanics, correct planning, and the correct prescription, treatment time and appointments can be reduced. Average interval is a little more than 10 weeks.
Please note: SLBs by themselves do not shorten treatment time or the number of appointments. However, to duplicate what SLBs do would require placing steel ligatures on each tooth. If that is not done, the patient must be seen more often. SLBs equal appointment efficiency.

Who wouldn't want that? You can bet your patients do.



Dr. Ronald Roncone received his BA, DDS, and MS in physiology from Marquette University, and his postdoctoral Certificate in Orthodontics from Forsythe Dental Center and Harvard School of Dental Medicine. Roncone maintains a large practice in Vista California, with 55 percent adult patients. He has lectured extensively, presenting more than 1,000 seminars around the world. He is also the president and CEO of Roncone Orthodontics International (ROI). ROI offers practice management courses, as well as in-office consulting and marketing services.


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